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Updated March 27, 2007

Case 5: Homelessness and HIV

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A 36-year-old homeless HIV-infected man with CD4 count of 102 cells/mm3 and an HIV RNA level of 122,000 copies/ml presents for follow-up after a recent hospitalization with Pneumocystis pneumonia. He was diagnosed with HIV at the time he was hospitalized. The only medication that he is taking is trimethoprim-sulfamethoxazole (Bactrim, Septra), two double strength tablets three times per day; he states he is taking most of the doses. He has been homeless for several years, sometimes staying in shelters or hotels, but often on the street. He has no income and no insurance. He was released from the hospital to a respite shelter where he could stay during daytime hours and receive medications and meals. The visiting nurse program for the county evaluates him in the shelter and informs you he has improved and will be discharged from the shelter in several days. Other medical problems include schizoaffective disorder and injection drug use. Overall, he states he is feeling much better than when in the hospital, but he has some residual dyspnea on exertion. He kept his first appointment with you after release and you have started counseling him regarding his HIV.

Which of the following statements is most accurate regarding the management of this HIV-infected homeless individual?

A Homelessness should be considered a clear-cut contraindication for initiating antiretroviral therapy.
B Homeless (or marginally-housed individuals) uniformly have low rates of adherence to antiretroviral medications.
C In the United States, HIV infection is more prevalent among the homeless population than it is in the overall population.
D Incentive programs for cash and food have not been successful in improving adherence in HIV-infected homeless individuals.